Dec 9, 2017

Of Raw Rage that Galvanized Grief

There's a rage in every grief. It can be a small thing - the silent clench of hand, the murderous angry stare that aptly targeted to everything and everyone, or the slow, hot drops of tears as curses fly at the world and its unfairness. It can also be huge and eruptive - the wretched wails, the uncontrollable violence and mayhem, or the sheer explosive of raw anger at the misfortune that befall.

I've witnessed the latter kind of grieving anger today when one of the patients died, in the day of relative tranquility often found when working over the weekends. I have seen a lot of families with their relative succumbed to death in the hospital. It was never a pretty sight. It was a horrid affair, it is horrible to witness, and it sticks to mind too long when it should have been long forgotten.

After some time, you will get used to this. Trust me, you will, whether you like it or not. Death to a person is as common as patients getting better after a treatment. One death does not mean the end of care to other patients. We allow relatives to have one final moment with the deceased and then it is back to business - the burial permit, the funeral, the wake, the mortuary, so on and so forth. We cleaned up the bed after the body has been transported, the ticket folder then will be filed at the counter, and soon afterwards a new occupant of the bed will arrive to ward. New case, new illness, and new possible mortality.

Over time we will get better at handling deaths in the ward. We will be able to anticipate when and which patient who will deteriorate and eventually die based on the degree of the illness and the plateaued responsiveness to treatment. One of the pitfalls in managing acute cases is the tendency of pronouncing Death In Line (DIL) prematurely (like you are giving up so soon?) and issuing the next step, No Active Resuscitation (NAR) (That's it? That's all you're gonna do? Just wait and see when they will die?). These two are deeply complicated issues and not the main topic right now. I'm just merely outlining the ways we deal with the impending death the best that we can.

The girl that I saw today was not issued a DIL nor an NAR. It was not even a calculated risk that she would passed away so suddenly. She was three years younger than my sister; small-frame body and skinny. She had a small flowery piercing on her nose. She had a small face with medium length black hair. She was brought to the emergency department yesterday early in the morning with fast breathing and fever. She was a known case of tuberculosis (batuk kering) which she got it from her sister sometime in the past and the family claimed she was compliant to her medications. Her lungs were full with crepitations - it was a case of very severe lung infection (pneumonia) complicated with her pulmonary tuberculosis.

This morning, around 8.30 am, my colleague who was working post night covering the ward she was in informed us that the she was intubated because of her worsening respiratory distress. They had to manually bagging her for hours while waiting for the ventilator to be brought down to the ward. I at that time naturally did not pay heed to it because usually an intubated patient will be taken over by Anaesthesia team and be transferred out to ICU. Plus, usually, although we, the ones who are working in the dengue ward also have to cover for the said ward (it is the Infectious ward, for cases like CRE (Carbapenem-Resistant Enterobacteriaceae), MRO (Multi-Resistant Organism), ESBL (Extended Spectrum Beta Lactamase) and all other horrifying infectious acronyms you can think of), they usually will call us for simple tasks like inserting lines or taking some blood tests.

I received a call around 3.45 pm, asking for some male houseman to come and help with CPR. Immediately I know this is about the same intubated patient. And so I ran, bringing with me the cardiac monitoring they begged to borrow. The specialist who was in the dengue ward with me walked in front of me, both of us were going to assist the oncall MO and my colleagues who were attending her at the moment.

The mother, eyes red and wet was sitting on a stool at the entrance of the ward. The pathway to ward is secluded; it was a secluded ward to begin with where you have to walk along the corridor of the building ward block to reach the ward. She was talking over the phone while sobbing into her handkerchief. We entered the ward, reached the room she was in, donned the N95 respirator "duck" mask with gloves on and apron ready, and helped with the resuscitation.

Suddenly there's a commotion outside the room. The room has a window that connects it with the outside pathway corridor, where her siblings were shouting as they saw what we were doing. In a midst of urgency and chaos, curtains were drawn and bed sheet were spread to block the view. We have been doing the compression and bagging for half an hour, IV adrenaline shots were given, and the specialist decided she needed to talk with the relative. She asked me to accompany her, seeing that the relatives were unbalanced in their grief and my tall stature may provide some security.

We met up at the corridor pathway outside, in front of the elderly mother who looked up at the specialist, tongue all tied up. The specialist then explained to them about the current situation that was happening, what we were doing at the moment, and that they have to brace themselves to a fact that she might not make it.

The brother was shouting at us; I thought he might be saying that it was all very sudden - one day they brought her here, and the next day she was intubated and was going to die? The other older brother was squatting against the wall outside the room she was in. He was crying, sobbing uncontrollably while the youngest of all, the little sister maybe 7 or 8 years old of age, not quite understanding what was going on with her family and more concerned towards her crying mother, was standing with her hands on her mother's shoulder while looking at us.

We came back inside to resume attending the patient and after 40 minutes of fruitless resuscitation, we pronounced her dead at 4.02 pm. We tidied up the room, we covered her with her shirt and tucked her back under the blanket. This is very crucial - we are preparing for the final moment of her with her family. Once everything is presentable, we asked the family to come in and see her for the last time.

And thus, was the first time I saw anger, at its most horrid, as a stage in grief. The mother couldn't even walk, she had to be supported by the staff. A chair was prepared and she collapsed into it, bursting with tears outside the room. The brothers were shouting in tears at the deceased, heads banged repeatedly with their hands and walls were punched again and again. That indescribable feeling of denial, the disbelief, the cruelest shock of one dearest being taken away so suddenly from their lives manifested as pure anger so gut retching you could almost feel it radiating into you. So much so that you couldn't handled it even though all you wanted to do was to embrace them tightly in sadness as to share the pain, to lessen the grief. None of us could handle the raging grief so we all hurriedly left the room, leaving them to grief in their own way.

Once they all have calmed down, then the natural order of things took over. The matter of transportation, the permits, the documentations. Yes, they were still grieving, but there are still many things to take care of. Soon afterwards, a retrospective entry was made by us to document what was happening. I collected my belongings I threw when I first came running into the ward, pushing along with me the cardiac monitoring machine and began walking back towards my ward.

No matter how many times I see death that comes and grief that is being left behind, it is always unsettling. There are things that we, as a body of healthcare professionals can improve on, and things that us, as a community can learn on. May the occasional deaths and the shake ups of grief that accompany them bring about a better approach towards care of the patients and their end-of-life treatment. Amin.